Medicare Payment for
Mental Health Services
Iowa Coalition on Mental Health & Aging
Presented by
Wisconsin Physicians Service (WPS)
Medicare Part B
Ellen Berra
Provider Outreach & Education
October 20, 2009
1
Agenda
„ Resources
„ Medicare Mental Health Care Providers
„ Indications and Limitations of Coverage
„ Type of Treatment Considered for Payment
„ Outpatient Mental Health Limitation
2
Resources
„ The Centers for Medicare & Medicaid
Services (CMS) Internet Only Manual (IOM)
Publication 100-02, Chapter 15, Section 80.2
– Psychological Tests and
Neuropsychological Tests
„ The CMS IOM Publication 100-02, Chapter
15, Section 160 – Clinical Psychologist
Services
„ The CMS IOM Publication 100-02, Chapter
15, Section 170 – Clinical Social Workers
3
Resources
„ The CMS IOM Publication 100-03, Chapter 1,
Part 2, Section 130 – Mental Health
„ The CMS IOM Publication 100-04, Chapter
12, Section 150 – Clinical Social Workers
„ The CMS IOM Publication 100-04, Chapter
12, Section 160 – Independent Psychologist
Services
4
Resources
„ The CMS IOM Publication 100-04, Chapter
12, Section 170 – Clinical Psychologist
Services
„ The CMS IOM Publication 100-04, Chapter
12, Section 210 – Outpatient Mental Health
Limitation
„ Website address:
http://www.cms.hhs.gov/Manuals/IOM/list.asp
#TopOfPage
5
Resources
„ Medicare Learning Network (MLN) Matters
Special Edition SE0441
„
Website Address:
http://www.cms.hhs.gov/MLNMattersArticles/d
ownloads/SE0441.pdf
6
Resources
„ Local Coverage Determination (LCD) L26690
– Psychiatry and Psychological Services,
Incident to
„ LCD L26691 – Psychiatric Pharmacotherapy
„ Website address:
http://www.wpsmedicare.com/j5macpartb/poli
cy/active/local/
„
Then choose your state
7
Coding Resources
„ American Medical Association (AMA)
http://www.ana.assn.org
„ CPT Information Services (CPTIS)
1-800-634-6922
„ General HCPCS Coding Questions
http://www.cms.hhs.gov/medHCPCSGenInfo/
20_HCPCS_Coding_Questions.asp#TopOfP
age
8
Appropriate Providers
„ Services can be provided by:
Physician MD or DO
„ Clinical Psychologist (specialty 68)
„ Clinical Social Worker (specialty 80)
„ Independent Psychologist (specialty 62)
„ Nurse Practitioner (specialty 50)
„ Clinical Nurse Specialist (specialty 89)
„ Physician Assistant (specialty 97)
„
9
Incident to Guidelines
„ Applies to services and supplies provided in
the office
„ Includes drugs and biologicals
„ Services can be provided incident to the
physician or the non-physician practitioner
(NPP)
10
Incident to Guidelines
„ Must be an integral, although incidental part
of the provider’s professional service
„ Commonly furnished without charge or
included in the provider’s bill
„ Commonly furnished in a provider’s office
„ Furnished under direct supervision
11
Incident to Guidelines
„ Providers must be acting within their scope of
practice
„ Legally authorized to practice
„ Claim can be submitted by the supervising
physician
„
Must meet the “direct supervision”
requirements
12
Non-Physician Practitioner (NPP)
Billing
Incident to billing
„ Bill under supervising
physician’s National
Provider Identifier (NPI)
„ Services provided
under direct supervision
„ Meet incident to
guidelines
„ See established
patients
„ Allowed at 100% of the
fee schedule
Direct/Independent Billing
„ Bill under his/her own
NPI
„ Work collaboratively or
under general
supervision of a MD/DO
as required by law
„ See new and
established patients
„ Allowed at percentage
of Physician Fee
Schedule
13
Physician’s office within an Institution
„ Must be confined to a separately identified
part of the facility used solely as the
physician’s office and cannot be construed to
extend throughout the entire institution
„ Services performed outside the “office” areas
Subject to the coverage rules outside an office
setting
„ Could be subject to facility pricing
„
14
Covered Services
„ Psychiatric Diagnostic Interviews
„ Psychological/Neuropsychological Testing
„ Psychotherapy Services
„ Therapeutic Activity Programs
„ Pharmacotherapy
„ Other Psychiatric and Psychological Services
15
General Clinical Psychiatric Diagnostic
or Evaluative Interview (90801)
„ Covered once at the outset of the illness
„ Patient has a suspected or diagnosed
psychiatric illness
„ Code is not time related
„ If no mental illness is present use diagnosis
code V71.09
„ Can use Evaluation and Management (E/M)
services including consultation codes provided
all required elements are present
16
Special Clinical Psychiatric Diagnostic
or Evaluative Procedure (90802)
„ Includes the same components and
requirements of 90801
„ Accomplished through the use of inanimate
objects, physician aids, and non-verbal
communication
„ If patient is incapable of communicating by any
means, this code is not appropriate
17
Psychiatric Therapeutic Procedures
(90804 – 90829, 90845 – 90865)
„ The appropriate psychotherapy code is chosen
on the basis of
Type of psychotherapy
„ Place of service
„ Face-to-face time spent with the patient
„ Whether E/M services are furnished on the same
day
„
18
Non-Covered Services
„ There is no Medical Necessity
„ The service provided are
Grooming skills
„ Activities of daily living
„ Recreational therapy
„ Social interaction
„
„ There service is not expected to prevent
relapse or hospitalization or to improve or
maintain level of functioning
19
Family Psychotherapy
(90846, 90487, and 90849)
„ Primary purpose must be treatment of the
patient’s condition
„ Efforts are for benefit of the patient, not
assisting the family members in
understanding the patient’s problem
20
Group Psychotherapy
(90853, 90857)
„ Must be led by a person who is authorized by
State Statute to perform the service
„ Group size should be a maximum of 12 people
„ Medicare coverage does not include
socialization, music, recreational activities, art,
or motion therapy, etc.
21
Pharmacologic Medication
Management (90862)
„ Includes prescribing, monitoring effects, and
adjusting dosage
„ Service is in-depth management of potent
medications with frequent serious side effects
„ The patient is primarily managed by
psychotropic drugs
22
Pharmacologic Medication
Management (90862)
„ Cannot by billed by a Clinical Psychologist
(CP) or a Clinical Social Worker (CSW)
„ A provider’s scope of practice must authorize
him/her to prescribe medication
„ This service is included in E/M and
psychotherapy services received on the same
day
23
Pharmacologic Medication
Management (M0064)
„ Brief office visit for monitoring, or changing
drug prescriptions used in mental health
treatment
„ Time spent with patient is generally less than
10 minutes
„ This service is included in E/M and
psychotherapy services received on the same
day
24
Central Nervous System Testing
(96101 – 96125)
„ These services are not psychotherapeutic
modalities, but instead are diagnostic aids
„ Standardized batteries of test are not
considered medically necessary by Medicare
„ Reading of the report is not a separately
payable service
25
Central Nervous System Testing
(96101 – 96125)
„ The code description shows when time is
associated with the procedure
Bill one unit of time when 30 minutes to 1 hour
is spent in the administration, interpretation
and report of the test
„ Bill multiple units for each additional hour
„ Services performed on multiple days are billed
on the last date of the service
„ There is no service billable if the time spent is
less than 30 minutes
„
26
Central Nervous System Testing
(96101 – 96125)
„ The procedure code indicates who is required
to perform the service
Physician or psychologist
„ Technician
„ Computer, with qualified health care
professional interpretation and report
„
27
Central Nervous System Testing
(96101 – 96125)
„ 96101 should not be paid when billed for the
same tests or services performed under
codes 96102 or 96103
„ 96118 should not be paid when billed for the
same test or services performed under 96119
and 96120
28
Documentation Requirements
„ The patient’s medical record should contain
documentation to support the medical
necessity for psychiatric services and that
psychiatric services were performed
„ Individual psychotherapy CPT codes should
only be used when the focus of the treatment
involves individual psychotherapy
29
Documentation Requirements
„ The medical record should document:
The patient’s capacity to participate in and
benefit from the therapy
„ The target systems,
„ Goals of therapy,
„ Methods of monitoring, and
„ Why the chosen therapy is the appropriate
treatment modality (either in lieu of, or in
addition to, another form of psychiatric
treatment)
„
30
Outpatient Mental Health Payment
Limitation
„ The limitation applies to both procedure
codes and diagnosis codes in an outpatient
setting
„ The limitation can apply to outpatient medical
services when the diagnosis code is a mental
health diagnosis
„ The limitation is 62.5% of the Medicare
Physician Fee Schedule
31
Outpatient Mental Health Payment
Limitation
„ Example: Billed amount is $125.00
Fee Schedule allowed amount is $100
„ Mental Health Allowed amount is 62.5% or
$62.50
„ Medicare pays 80% or $50.00
„ Patient is responsible for $50.00
„ Providers should be aware of the assignment
agreement and the Limiting Charge
„
32
Outpatient Mental Health Payment
Limitation
„ Payment for psychological and
neuropsychological tests are not subject to
the outpatient mental health treatment
limitation
„ Payment for the initial assessment –
procedure codes 90801 and 90802 are not
subject to the limitation
„ Payment for a brief office visit to monitor or
change drug prescriptions – M0064 – is not
subject to the limitation
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Questions???
34
Thanks!!!
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